- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,532.24 / $1,532.24 / $3,934.14
| Facility | | $1,532.24 | $1,532.24 | $3,934.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,532.24 / $2,110.21 / $3,934.14
| Professional | | $1,532.24 | $2,110.21 | $3,934.14 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $4,729.35 / $4,729.35 / $4,729.35
| Facility | | $4,729.35 | $4,729.35 | $4,729.35 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,739.20 / $3,043.56 / $5,278.65
| Professional | | $2,739.20 | $3,043.56 | $5,278.65 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $3,001.57 / $3,001.57 / $3,481.66
| Facility | | $3,001.57 | $3,001.57 | $3,481.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,191.15 / $3,001.57 / $3,225.66
| Professional | | $2,191.15 | $3,001.57 | $3,225.66 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,826.14 / $1,975.10 / $3,291.83
| Professional | | $1,826.14 | $1,975.10 | $3,291.83 |